31A-29-110 - Pool administrator -- Selection -- Powers.
31A-29-110. Pool administrator -- Selection -- Powers.
(1) The board shall select a pool administrator in accordance with Title 63G, Chapter 6,Utah Procurement Code. The board shall evaluate bids based on criteria established by theboard, which shall include:
(a) ability to manage medical expenses;
(b) proven ability to handle accident and health insurance;
(c) efficiency of claim paying procedures;
(d) marketing and underwriting;
(e) proven ability for managed care and quality assurance;
(f) provider contracting and discounts;
(g) pharmacy benefit management;
(h) an estimate of total charges for administering the pool; and
(i) ability to administer the pool in a cost-efficient manner.
(2) A pool administrator may be:
(a) a health insurer;
(b) a health maintenance organization;
(c) a third-party administrator; or
(d) any person or entity which has demonstrated ability to meet the criteria in Subsection(1).
(3) (a) The pool administrator shall serve for a period of three years, with two one-yearextension options, subject to the terms, conditions, and limitations of the contract between theboard and the administrator.
(b) At least one year prior to the expiration of the contract between the board and thepool administrator, the board shall invite all interested parties, including the current pooladministrator, to submit bids to serve as the pool administrator.
(c) Selection of the pool administrator for a succeeding period shall be made at least sixmonths prior to the expiration of the period of service under Subsection (3)(a).
(4) The pool administrator is responsible for all operational functions of the pool andshall:
(a) have access to all nonpatient specific experience data, statistics, treatment criteria,and guidelines compiled or adopted by the Medicaid program, the Public Employees Health Plan,the Department of Health, or the Insurance Department, and which are not otherwise declared bystatute to be confidential;
(b) perform all marketing, eligibility, enrollment, member agreements, andadministrative claim payment functions relating to the pool;
(c) establish, administer, and operate a monthly premium billing procedure for collectionof premiums from enrollees;
(d) perform all necessary functions to assure timely payment of benefits to enrollees,including:
(i) making information available relating to the proper manner of submitting a claim forbenefits to the pool administrator and distributing forms upon which submission shall be made;and
(ii) evaluating the eligibility of each claim for payment by the pool;
(e) submit regular reports to the board regarding the operation of the pool, the frequency,content, and form of which reports shall be determined by the board;
(f) following the close of each calendar year, determine net written and earned premiums,the expense of administration, and the paid and incurred losses for the year and submit a report ofthis information to the board, the commissioner, and the Division of Finance on a formprescribed by the commissioner; and
(g) be paid as provided in the plan of operation for expenses incurred in the performanceof the pool administrator's services.
Amended by Chapter 382, 2008 General Session